WASHINGTON—In 2005, VA initiated a Colon Cancer Care Collaborative (C4) to help improve the timeliness of follow-up after positive fecal blood occult tests (FOBT). The initiative was in reaction to studies released at the time showing considerable delays between screening and follow-up, some as long as six months to a year.

Six years later, that initiative has shown success in some areas, but FOBT follow-up still falls short of the goal set by VA.

“Timely follow-up is a problem in VA and other health-care systems,” explained Adam Powell, PhD, a researcher at the Minneapolis VA Center for Chronic Disease Research. “Most people consider six months to be an unacceptable delay.”

Over the time period, the C4 initiative grew to include 21 facilities—one from each Veterans Integrated Service Network—with phase one being to improve FOBT follow-up practices. Each facility developed a quality-improvement team, received quality- improvement training, and implemented process changes. What the teams learned along the way was disseminated throughout all facilities that were part of the initiative.

“This was a very high visibility project, and as quickly as we got into it, it was clear that this was going to turn into a national effort,” Powell said, describing the outcome of the initiative at the VA Health Services R&D conference. “A variety of shadow collaboratives started up while we were still in the midst of this project. There were many non-C4 sites doing this. It was very hard to identify controls.”

However, Powell and his colleagues eventually identified three control sites in VA which had put none of the collaboratives’ initiatives into effect to compare to the 21 official C4 sites. He and his colleagues conducted an evaluation of changes in the timeliness of follow-up among participating facilities. The primary outcome measure was the change in the percentage of patients receiving a follow-up colonoscopy within 60 days of a positive FOBT screening among all patients receiving a colonoscopy within a year. Secondary measures included the percent of patients receiving a colonoscopy within one year of a positive FOBT and average days to colonoscopy.

Overall, the study included about 20,000 FOBT screenings performed by the facilities before and after the initiative began.

Using the 60-day measure, there was a 12% increase in patients receiving a colonoscopy in that timeframe in the C4 sites. In non-C4 sites, there was actually a decrease in timely colonoscopies—dropping from 45% to 29% of patients. The average delay from a positive FOBT to colonoscopy in C4 sites was 129 days prior to the initiative and 103 days afterward. The average delay in non-C4 sites was 81 days prior to the initiative and 102 afterward.

Powell noted, however, that the 103-day average in the C4 facilities is still well short of VA’s 60-day goal for a colonoscopy following a positive FOBT.

The C4 sites posted a 10% increase among patients receiving colonoscopies within one year. However, there was a similar increase in the control sites. “It’s very possible it was a trend that had nothing to do with C4,” Powell said.

Researchers surveyed the C4 teams to try and get a sense of what factors might have predicted improvement. The biggest correlate between improvement in terms of care strategy was found in facilities that engaged in primary-care education for providers.

Also, based on the responses, facilities that had set clear goals and identified their goals upfront were the teams that appeared to do best, Powell said. “There really is no evidence base on how you go about getting this done. The teams really needed to hone in and identify goals and figure out who was going to do them.”